Date : 01/20/98
Page : 1

JFK ASSASSINATION SYSTEM
IDENTIFICATION FORM

AGENCY INFORMATION

; AGENCY : INSCOM/CSF
RECORD NUMBER : 194-10004-10141
RECORDS SERIES : DOD-AFFILIATED PERSONNEL INCIDENT INVESTIGATIONS
AGENCY PILE NUMBER : PAGES 378-381

DOCUMENT INFORMATION

ORIGINATOR : USA,
FROM : HAYASHIDA, MYRON K.
; TO :
TITLE : [ RESTRICTED ]}
DATE : 11/26/66
PAGES : 4 ;
SUBJECTS : FROMER, DAVID R.

LEGAL ADVICE

DOCUMENT TYPE : PAPER, TEXTUAL DOCUMENT
CLASSIFICATION : UNCLASSIFIED
' RESTRICTIONS : 3 -
CURRENT STATUS : RELEASED WITH DELETIONS
DATE OF LAST REVIEW : 03/07/95
OPENING CRITERIA :
COMMENTS

NW 60613 Docid:34528582 Page 1

Co |

i
N

STATEMENT O. .ERSONAL HISTORY

INSTRUCTIONS: Read the certification at the end of this questionnaire before entering the required data. Print or type all
answers. All questions and statements must be completed. If the answer is ‘‘None,"’ so state. Do not misstate or omit material
fact since the statements made herein are subject to verification. If more space is needed, use the Remarks section, item 20, and
attach additional sheets if necessary. The information entered hereon is for official use only and will be maintained in confidence.

rint) FIRST NAME—MIDDLE NAME--MAIDEN NAME (If any)—LAST NAME
2. STATUS

Clues. DAVID REED FROMER
OD miss Gcvum [| MILITARY ON ACTIVE DUTY
f 3. ALIAS(ES). NICKNAME(S). OR CHANGES IN NAME (Other than by marriage) 4, PERMANENT MAILING ADDRESS
None 13 Rhonde Way, Mill Valley, Calif.

5. DATE OF BIRTH (Day, month, year) PLACE OF BIRTH (City, County, State, and Country)

21 July 1942 Chicago, Cook, Illinois, USA

RACE HEIGHT WEIGHT COLOR OF EYES COLOR OF HAIR SCARS, PHYSICAL DEFECTS. DISTINGUISHING MARKS
Cauc 67" 1768 Brown Brown Scar above left eye
6. DO YOU HAVE A HISTORY OF MENTAL OR NERVOUS DISORDERS? UO YESHS NO ARE YOU NOW OR HAVE YOU EVER BEEN ADDICTED TO THE USE OF HABIT FORMING DRUGS SUCH AS.

NARCOTICS OR BARBITURATES? oO YES Xo ARE YOU NOW OR HAVE YOU EVER BEEN A CHRONIC USER TO EXCESS OF ALCOHOLIC BEVERAGES? im) YES EXno IF THE ~
ANSWER TO ANY OF THE ABOVE IS "'YES."" EXPLAIN IN ITEM 20.

7U.S. IF NATURALIZED, CERTIFICATE NO. IF DERIVEO, PARENTS’ CERTIFICATE NO(S), | DATE. PLACE, AND COURT

CITIZEN
a” be
r Pre ee

_
= ATION N N NTRY DATE AND PORT OF ENTRY DO YOU INTEND TO BECOME
EGISTRATION NO ATIVE COU! ALU. S. CITIZEN?
YES NO.
8.

MILITARY SERVICE
ARE YOU PRESENTLY ON ACTIVE DUTY IN THE U. S. ARMED FORCES DRAWING FULL PAY? [_] YES KX] NO IF “YES,” COMPLETE THE FOLLOWING:
GRADE AND SERVICE NO. SERVICE AND COMPONENT ORGANIZATION AND STATICN

PLACE CERTIFICATE RECCRDED

ARE YOU PRESENTLY A MEMBER OF A U. S. RESERVE OR NATIONAL GUARD ORGANIZATION? Oo yes [4 No F “YES. COMPLETE THE FOLLOWING:
GRADE AND SERVICE NO, SERVICE AND COMPONENT ORGANIZATION AND STATION OR UNIT AND LOCATION ,

HAVE YOU PREVIOUSLY SERVED TOURS OF EXTENDED ACTIVE DUTY. DRAWING. FULL PAY. FROM WHICH YOU WERE DISCHARGED OR SEPARATED'TO CIVILIAN STATUS? G ves [
IF ‘"YES.*' COMPLETE THE FOLLOWING: :

CCUNTRY ‘ COMPONENT FROM (Date) TO (Date) TYPE DISCHARGES OR SEPARATIONS—GRADE AND SERVICE NO.

9%. EDUCATION (Account for all civilian schools and military academies. Do not include service schools)

ee ee | ves |

| 1947 | 1949 |S Nettelhorst Elem. School, Chicago, Illinois |X| xf.

1950 La Casita Elem. School, Clovis, New Mexico | */ x po
x

1950 1954 Argonne Elem. School, S.F., Calif.

NAME AND LOCATION OF SCHOOL DEGREE

0.

FAMILY (Lise in order given, parents, spouse, guardians, stepparents, foster parents, parents-in-law, former spouse(s) (if divorced give date
and place), children, brothers and sisters, even though deceased. Include any others you resided with or with whom a close relationship
existed or exists. /f the person is not a U. S. citizen by birth, give date and port of entry, alien registration number, naturalization certificate
number and place of issuance.)

RELATION AND NAME PRESENT ADORESS, IF LIVING

13 Rhonda Way

DATE AND PLACE OF BIRTH

12 July 1913
Cincinnati, Ohio
31 Dec 1909

Estherville owa

FATHER

IRVING FROMER

MOTHER (Maiden name)

Katherine Rhodes

SPOUSE (Maiden name)
None

OTHER (Specify) Brother
Jon Fromer Chicego, Illinois

Sister 15 Aug 1939 881 Clayton St.
Ann Speke San Francisco, Calif. | San Francisco, Calif.

Calif.

PREVIOUS EDI‘ IONS ARF, OBSOLETE. ’ 7 Exception to Standard Form 86 : é
vi gets eta se OBpage MftONS vend AEEICIAL PISE ONLY” ‘Approved by Bureau of the Budert, Tune 1980

a oro]
GN COUNTRIES (List 4randparents, first cousins, aunts, uncles,

J:ip existed or exists)

OTHER RELATIVES ANO ALIEN FRIENDS LIVING IN FORE!

brothers- and sisters-in-law, and other persons with whom a close relations.

ADDRESS

13. EMPLOYMENT (Show every employment you have had and all periods of unemployment)

Peul Elder Scokstore | mut elder __ 2 P
Dec 59 | Sutter & Stockton Sts.,S al, | Pay de season
San Francisco Council Camp Fire unknoon | End of summer
Girls, SeFe Calif. Camp
Fairmont Hotel Part-time
1861 San Francisco, Calif nknown job :
Foster's Restaurant ‘pertetime job _
an an Sco = P fadi Bacon camp
Madison Soard of Education Rec. ecnoun end of school
Madison, Wisconsin eer
Clark Service Station | a cutter Conflict with
Atwood Ave, ,fladison, Wisconsin Ed Cutte studies
folk trio
1718 Wells St.,Chicago,Illinoia | Bob George 5.F.

SOCIAL SECURITY NO.

DID ANY OF THE ABOVE EMPLOYMENTS REQUIRE A SECURITY CLEARANCE? ( Yes &XNO DO YOU HAVE
ANY FOREIGN PROPERTY OR BUSINESS CONNECTIONS, OR HAVE YOU EVER BEEN EMPLOYED BY A FOREIGN -
GOVERNMENT, FIRM, OR AGENCY? [] YES XX NO HAVE YOU EVER BEEN REFUSED BOND? [_] YES
KKKNO IF THE ANSWER TO ANY OF THE ABOVE IS "YES," EXPLAIN IN ITEM 20.

i
t

Dec 59

It

1960

1961

1962 &

Fall 196

Oct 65

564-538-8137

ons living outside the

“ CREDIT AND CHARACTER REFERENCES (Do not include relatives, former employers, or pers
United States or its Territories. : :

N | YEARS
(List 3 credit and 5 character) * KNOWN

None.

. STREET AND NUMBER STATE OR
Malvina Reynolds : 2027 Parker Street : Calif. |
eaphan Negossce ip | Sonore Way =

E

|

Madi Be aith Aver [ca1ie. _|

Archie Brown

CHARACTER

L

NW 88613 Docid:34528582 Page 3

U.S. GOVERNMENT PRINTING OFFICE : 1860 O—S573450

STREET AND NUMBER

city STATE OR COUNTRY
—1s09-| vere prne_trave street [thicago___|fldinoie
Eduarde Street [Clovie 1]
8

iw F4

alifornia
Berkele

1961. - 81 Clayton Street San Francisco
1962, | sd] 29 N. Basset fladison
|

alifornia
elifornia
sconsin
sconsi

| 1942" | i
349 lew Mexico
1950 1960 1932 Cabrilléd Street San_ Francisco
| 1960 | 2850 Azncroft Wa

:

215 Lake Lawn Avenue
1427 University Avenue adison sconsin
881 Clayton Strest Sen Francisco [California
435 W. North Avenue

| 1963 [1964 |

| 1966 [1965 |

| i966 [| ~=«13 Rhonda Wa Mill Valle
| 1966 [|

a

= 3
[o]
[a3
=
io
Ls]
=]

140 Lengdon Street jisconsin
PAST AND/OR PRESENT MEMBERSHIP {N ORGANIZATIONS

ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF THE COMMUNIST PARTY U.S. A., OR ANY COMMUNIST ORGANIZATIONS ANYWHERE? '
| | ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF A FASCIST ORGANIZATION?

1 :
ARE YOU NOW OR HAVE YOU EVER SEEN A MEMBER OF ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP OR COMBINATION OF PERSONS WHICH ADVOCATES THE
OVERTHROW OF OUR CONSTITUTIONAL FORM OF GOVERNMENT, OR-WHICH HAS ADOPTED THE POLICY OF ADVOCATING OR APPROVING THE COMMISSION OF ACTS OF FORCE
OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF THE UNITED STATES, OR WHICH SEEKS TO ALTER THE FORM OF GOVERNMENT OF
THE UNITED STATES BY UNCONSTITUTIONAL. MEANS?

ARE YOU NOW OR HAVE YOU EVER BEEN AFFILIATED OR ASSOCIATEO WITH ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE AS AN AGENT. OFFICIAL, OR EMPLOYEE?

ARE YOU NOW ASSOCIATING WITH, OR HAVE YOU ASSOCIATED WITH ANY INDIVIDUALS, INCLUDING RELATIVES, WHO YOU KNOW OR HAVE REASON TO BELIEVE, ARE OR
HAVE BEEN MEMBERS OF ANY OF THE ORGANIZATIONS IDENTIFIED ABOVE? :

HAVE YOU EVER ENGAGED IN ANY OF THE FOLLOWING ACTIVITIES OF ANY ORGANIZATION OF THE TYPE DESCRIBED ABOVE: CONTRIBUTION(S) TO, ATTENDANCE AT OR
PARTICIPATION IN ANY ORGANIZATIONAL. SOCIAL. OR OTHER ACTIVITIES OF SAID ORGANIZATIONS OR OF ANY PROJECTS SPONSORED BY THEM: THE SALE, GIFT.OR bis-
TRIBUTION OF ANY WRITTEN, PRINTED, OR OTHER MATTER, PREPARED, REPRODUCED, OR PUBLISHED, BY THEM OR ANY OF THEIR AGENTS OR INSTRUMENTALITIES?

IF“ YES,” DESCRIBE THE CIRCUMSTANCES. ATTACH ADDITIONAL SHEETS FOR A FULL DETAILED STATEMENT. IF ASSOCIATED WITH ANY OF THE ABOVE ORGANIZATIONS. SPECIFY NATURE
AND EXTENT OF ASSOCIATION WITH EACH, INCLUDING OFFICE OR POSITION HELD. ALSO INCLUDE DATES. PLACES. AND CREDENTIALS NOW OR FORMERLY HELD. IF ASSOCIATIONS HAVE
BEEN WITH INDIVIDUALS WHO ARE MEMBERS OF THE ABOVE ORGANIZATIONS, THEN LIST THE INDIVIDUALS AND THE ORGANIZATIONS WITH WHICH THEY WERE OR ARE AFFILIATED.

18. HAVE YOU EVER BEEN DETAINED, HELD, ARRESTED. INDICTED OR SUMMONED INTO COURT AS A DEFENDANT IN A CRIMINAL PROCEEDING. OR CONVICTED, FINED, OR IMPRISONED OR
PLACED ON PROBATION, OR HAVE YOU EVER BEEN ORDERED TO DEPOSIT BAIL OR COLLATERAL FOR THE VIOLATION OF ANY LAW, POLICE REGULATION OR ORDINANCE (excluding
minor traffic violations for which a fine or forfeiture of $25, or less was imposed)? INCLUDE ALL COURT MARTIALS WHILE IN MILITARY SERVICE. [] YES EXno
IF “YES."' LIST THE DATE, THE NATURE OF THE OFFENSE OR VIOLATION. THE NAME AND LOCATION OF THE COURT OR PLACE OF HEARING, AND THE PENALTY IMPOSED OR OTHER
DISPOSITION OF EACH CASE.

. Sat

wef al

“ - ee — : (

a“!

uve Beth I" AMEBIRSR Pag gg MTN ED HEREIN WHICH MAY arrircY UPON YOUR LOYALTY TO THE UNITED STATES OR UPON YOUR SUITABILITY TO PERFORM

4

A AN | ee
19. ARE THERE ANY INCIDENTS IN YOUR LIFE NOT MENTION ED HERTIN WHICH MAY REFLI -T UPON YOUR LOYALTY TO THE UNITED SfATES OR UPON YOUR SUITABILITY TO PERFOKM
THE DUTIES WHICH YOU MAY BE CALLED UPON TO TAKE OR WHICH MIGHT REQUIRE FURTHER EXPLANATION? Xx YES oO NO ” IF ‘'YES.’" GIVE DETAILS

lam a conscientious objector. My case is in the courts at the present time.

20, REMARKS

I have been advised by my lawyers thet I cannot sign #16 or #17 without
.putting myself in jeapatdy. Private attorney - Peter Frarck °
Family attorney - ViosabtiHallinan

°

David Reed Fromer, born 21 July 1942, in Chicago, Illinois,
.@ registrant under the Univers] Military Training Act, wes
_this date given an opportunity .to. execute OD Ferm 398 and
in my presence he refusad to do so, if ite entirety.

RON K. HAYQZSHIDA
1/LT, AGC
ITEM EDUCATION (Continued DEGREE

1960 - 1961 University of California, Berkeley, California No
1961 - 1962 City College of San Francisco, Sen Francisco, Calif. Yes
University of Uisconeiny Madison, Wisconsin

)

San Francisco State Col e, San Francisco, Calif. (Ext.)
Roosevelt University, Chi igs g0 Illinois , (

| CERTIFY THAT THE ENTRIES MADE BY ME ABOVE ARE TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND ARE MADE IN
GOOD FAITH. | UNDERSTAND THAT A KNOWING AND WILLFUL FALSE STATEMENT ON THIS FORM CAN BE PUNISHED BY FINE OR IMPRISONMENT OR BOTH
(See U.S. Code, title 18, section 1001)

21 Nov.1966 | HVAT eS HAYRSROHS 1/LT, AGG
1515 Clay St., Oakland, Calif.

2. THIS SECTION TO BE COMPLETED BY AUTHORITY REQUESTING INVES eg TIGATION yy
BRIEF DESCRIPTION OF DUTY ASSIGNMENT AND DEGREE OF CLASSIFIED MATTER (top secret, secret, etc.) TO WHICH APPLICANT WILL REQUIRE ACCESS

RECORD OF PRIOR CLEARANCES

DATE OF CLEARANCE TYPE OF CLEARANCE AGENCY THAT COMPLETED INVESTIGATION

* 58]

REMARKS,

Ay

NW 88613 Docld:34528582 Page 5 U.S. GOVERNMENT PRINTING OFFICE : 1960 O—373450


